Microbial stowaways in topical antiseptic products.

n engl j med 367;23 nejm.org december 6, 2012 2170 ing for MDR­GNRs are desper­ ately needed. Incorporating these fundamen­ tal prevention and control prac­ tices into the daily life of the hospital is difficult, as demon­ strated by persistently low rates of adherence even in the coun­ try’s most prestigious institutions. The Department of Health and Human Services and many orga­ nizations have invested heavily in programs aimed at improving per­ formance, but hospitals often ap­ proach each infection individually rather than redesigning frontline systems to facilitate adherence to best practices — for example, in­ corporating a set of critical prac­ tices, such as timely removal of in­ vasive devices and “de­escalation” of antibiotic treatment (including narrowing or discontinuing anti­ biotics once culture results are available), into a bedside check­ list. Multidisciplinary care path­ ways can incorporate standing­ order sets, checklists, and prompts (such as alerts to consider “seda­ tion vacation” for ventilated pa­ tients) that can facilitate not only adherence but also real­time data collection and feedback that re­ inforce social norms. Enhanced data collection can be accom­ plished through “random audits” 4 that target one key aspect of evi­ dence­based care at least weekly on rounds, with the team check­ ing adherence on a simple form at each bedside and sharing a tally and strategies for improve­ ment at the end of rounds. This data collection should be a seam­ less part of work, not extra labor performed by someone else. Even fastidious adherence to evidence­based practice does not guarantee immunity from MDR­ GNR outbreaks. Although relative­ ly rare, these outbreaks require ongoing vigilance, rapid epidemi­ ologic investigation, and prompt response.5 Common­source out­ breaks caused by contaminated solutions or equipment still oc­ cur despite advances in steriliza­ tion and disinfection, elimination of multidose containers, and pro­ cedures designed to minimize contamination during use. New resistant pathogens may emerge suddenly and escape the growing global surveillance network, arriv­ ing at the hospital door unher­ alded. But if hospitals develop reliable, evidence­based systems to minimize the MDRO threat, they will be able to refocus on developing innovative approaches to intercepting and mitigating new dangers. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.